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INTRODUCTION: Diversity has become a key-strategic element of success in various political and economic fields. The European Society of Intensive Care Medicine (ESICM) decided to make diversity a key strategic priority for the future and appointed a Task-Force on this topic. METHODS: In a consensus process, three Working-Groups, nominated by Task-Force members, developed statements on strategic future topics. In addition, diversity-related data available from the membership database have been analyzed and reported in aggregated form. RESULTS: The Task-Force decided to nominate working groups on (1) "sex, gender identity and sexual orientation", (2) "ethnicity, culture and socio-economic status", and (3) "multiprofessionalism". These are the first prioritized topics for the near future. The first diversity-report shows targetable items in all three domains. CONCLUSION: The diversity Task-Force defined actionable items for a one- and three-year plan that are especially aiming at the identification of potential gaps and an implementation of concrete projects for members of the ESICM.
Syndrome of trephined-underestimated and poorly understood complication after decompressive craniectomy.
Decompressive craniectomy (DC) is still a matter of debate, with a numerous complications as expansion of haemorrhagic contusions, external cerebral herniation, subdural hygromas, post-traumatic hydrocephalus (HC). The often overlooked "syndrome of the trephined" (ST) as a delayed complication of DC also known as sinking skin flap sy initially described in 1939.ST is characterised by the neurological changes associated with alteration of the pressure/volume relationship between intracranial pressure (ICP), volume of cerebrospinal fluid (CSF), blood, and brain tissue in patients with large bone defects. This review aims at elucidating the mechanisms responsible for the development of ST, and providing useful tips and red-flag signs for healthcare professionals involved with care of post DC patients. Symptoms identified on time could help to develop appropriate treatment strategies for this suddenly deteriorating, but possible reversible condition. Although the treatment strategy is straightforward, calling for a prompt cranioplasty, the correction of HC through CSF diversion devices might require a lengthy optimisation period. Continuous changes in the setting of the shunting systems or spinal tap might lead to dangerous swinging of the midline structures causing further neurological deterioration. Thus, finding the right balance in terms of clinical management often represents a significant challenge.
Comparison of the Asleep-Awake-Asleep Technique and Monitored Anesthesia Care During Awake Craniotomy: A Systematic Review and Meta-analysis.
Awake craniotomy (AC) is the preferred surgical option for intractable epilepsy and resection of tumors adjacent to or within eloquent cortical areas. Monitored anesthesia care (MAC) or an asleep-awake-asleep (SAS) technique is most widely used during AC. We used a random-effects modeled meta-analysis to synthesize the most recent evidence to determine whether MAC or SAS is safer and more effective for AC. We included randomized controlled trials and observational studies that explored the incidence of AC failure, duration of surgery, and hospital length of stay in adult patients undergoing AC. Eighteen studies were included in the final analysis. MAC was associated with a lower risk of AC failure when compared with SAS (global pooled proportion MAC vs. SAS 1% vs. 4%; odds ratio [ORs]: 0.28; 95% confidence interval [CI]: 0.11-0.71; P=0.007) and shorter surgical procedure time (global pooled mean MAC vs. SAS 224.44 vs. 327.94 min; mean difference, -48.76 min; 95% CI: -61.55 to -35.97; P<0.00001). SAS was associated with fewer intraoperative seizures (global pooled proportion MAC vs. SAS 10% vs. 4%; OR: 2.38; 95% CI: 1.05-5.39; P=0.04). There were no differences in intraoperative nausea and vomiting between the techniques (global pooled proportion MAC vs. SAS: 4% vs. 8%; OR: 0.86; 95% CI: 0.30-2.45; P=0.78). Length of stay was shorter in the MAC group (MAC vs. SAS 3.96 vs. 6.75 days; mean difference, -1.30; 95% CI: -2.69 to 0.10; P=0.07). In summary, MAC was associated with lower AC failure rates and shorter procedure time compared with SAS, whereas SAS was associated with a lower incidence of intraoperative seizures. However, there was a high risk of bias and other limitations in the studies included in this review, so the superiority of 1 technique over the other needs to be confirmed in larger randomized studies.
INTRODUCTION: Literature on New-Onset Refractory Status Epilepticus (NORSE) is scarce and management is guided mainly by retrospective reports, short case series or expert opinions. We aimed to add to the pool of the available data by retrospectively reviewing seven cases of NORSE cases admitted to our hospital over the last five years between January 2014 and March 2019. METHODS: Fully anonymised data from medical charts, EEG reports, imaging reports, laboratory test results, types of antiepileptic medications, intravenous anaesthetic therapy, and immune therapies received was collected, along with response to treatment, length of hospital stay and outcome at discharge. RESULTS: The mean age was 43.5 ± 23.8 years (range 18-75) and three patients were females. Prodromal symptoms consisted mainly of fever (4/7), headache (4/7) and self terminating seizures (7/7), before presenting with status epilepticus. Initial imaging findings were abnormal in 3/7 and CSF analysis in 3/7. All patients underwent intermittent EEG recordings, mainly for titration or tapering of the anaesthetic agents, with the initial goal of achieving burst suppression and cessation of electrographic seizures. Our index case spent the longest time in therapeutic burst suppression (102 days) and remained on thiopentone for 214 days. The mean duration of NICU stay was 88 ± 85.4 days (range 4-225 days) while the mean duration of hospital stay was 113.8 ± 111.2 days (range 17-292). CONCLUSIONS: The management of patients with NORSE remains challenging, often requiring multiple intravenous anaesthetic treatments, leading to complicated and prolonged hospital and intensive care unit stays but good outcome remains possible.
Cardiac abnormalities identified with echocardiography in anorexia nervosa: systematic review and meta-analysis.
BACKGROUND: Anorexia nervosa affects most organ systems, with 80% suffering from cardiovascular complications. AIMS: To define echocardiographic abnormalities in anorexia nervosa through systematic review and meta-analysis. METHOD: Two reviewers independently assessed eligibility of publications from Medline, EMBASE and Cochrane Database of Systematic Reviews registries. Studies were included if anorexia nervosa was the primary eating disorder and the main clinical association in described cardiac abnormalities. Data was extracted in duplicate and quality-assessed with a modified Newcastle-Ottawa scale. For continuous outcomes we calculated mean and standardised mean difference (SMD), and corresponding 95% confidence interval. For dichotomous outcomes we calculated proportion and corresponding 95% confidence interval. For qualitative data we summarised the studies. RESULTS: We identified 23 eligible studies totalling 960 patients, with a mean age of 17 years and mean body mass index of 15.2 kg/m2. Fourteen studies (469 participants) reported data suitable for meta-analysis. Cardiac abnormalities seen in anorexia nervosa compared with healthy controls were reduced left ventricular mass (SMD 1.82, 95% CI 1.32-2.31, P < 0.001), reduced cardiac output (SMD 1.92, 95% CI 1.38-2.45, P < 0.001), increased E/A ratio (SMD -1.10, 95% CI -1.67 to -0.54, P < 0.001), and increased incidence of pericardial effusions (25% of patients, P < 0.01, 95% CI 17-34%, I2 = 80%). Trends toward improvement were seen with weight restoration. CONCLUSIONS: Patients with anorexia nervosa have structural and functional cardiac changes, identifiable with echocardiography. Further work should determine whether echocardiography can help stratify severity and guide safe patient location, management and effectiveness of nutritional rehabilitation.
Background Despite its long history, dissociation remains under-recognised clinically, partly due to difficulties identifying dissociative symptoms. Qualitative research may support its recognition by providing a lived experience perspective. In non-affective psychosis, identification of dissociation may be particularly important given that such experiences have been implicated its development and maintenance. Therefore, this study aimed to understand in the context of psychosis: what it is like to experience dissociation; the impact dissociation might have; what factors begin, maintain or end dissociative experiences; and what beliefs people hold about dissociation. Methods Qualitative interviews were carried out with twelve NHS patients with non-affective psychosis diagnoses and experience of dissociation. Data were analysed using Thematic Analysis. Results Dissociation involves subjective strangeness, unreality, disconnection, and shifts in perception. It impacts on mental health (including psychotic experiences), daily functioning, emotional connection, and can lead to social withdrawal. Stress, fatigue, and excessive internal focus may be involved in development and maintenance. Participants found it very difficult to describe the experience of dissociation, and, as a result, often did not mention it to others. Even when shared, interviewees reported that their descriptions were misunderstood and therefore they did not receive information or support specific to dissociation. The consensus was that experiences of dissociation are negative, but that understanding them better helped to enable coping. Conclusions The core subjective experience of dissociation appears to be a felt sense of anomaly (FSA), and we therefore suggest clinicians proactively enquire about such experiences. Dissociation is distressing, and has multiple impacts, but can easily be overlooked due to difficulties describing it and behavioural similarities to negative psychotic symptoms such as withdrawal.